The Virginia Medicaid (Medallion II) and CHIP (FAMIS)
Program Expansion
Administered by The Department of Medical Assistance Services
DMAS’ mandatory managed care program using contracted Managed Care Organizations (MCO) marked
a 15-year anniversary on 1/1/11.
Enrollment - November 1, 2011:
Medicaid FFS 299,102
Medicaid (MEDALLION) PCCM 52,656
Medicaid MCO (Medallion II) 531,681
FAMIS FFS 7,838
FAMIS MCO 53,619
Managed Care Enrollment
Why Managed Care?Background
AccessThe Department does not have a network development team and therefore had access gaps. The MCOs were able to leverage their commercial and/or health system networks to increase access.
Quality The Department’s outcome measures were low (EPSDT, Immunization, Prenatal Care). MCO outcomes were higher. Requiring plans to have NCQA accreditation moved Virginia scores into higher percentiles.
Background
Credentialing The Department experienced concerns with some of the providers in the FFS networks (unverified qualifications, no site visits, no reporting mechanism). MCOs using NCQA standards have achieved superior networks through credentialing.
Member Service The Department was unable to develop a full service member service unit. MCOs are able to offer 24/7 call centers, member information and programs, outreach.
Background
Case Management The Department is unable to offer case management, chronic care management, enhanced prenatal care and disease management programs. The MCOs offer these programs plus predictive modeling and patient-centered care.
Cost The MCO program is full risk, thus it provides the Department with a stable predictor of costs.
Value Added Benefits of MCOs
Virginia is one in a handful of states that require our contracted MCOs to obtain National Committee for Quality Assurance (NCQA) accreditation.
NCQA is the gold standard in evaluating health plan quality by employers, consumers, regulators and health plans.
All current MCOs not only meet this requirement, they have all been ranked nationally by NCQA in the top 50 for 2011.
Provider Relations and dedicated provider staff.
Patient Education Information - Member handbooks, provider directories, newsletters and health information (available in English and Spanish).
Value Added Benefits of MCOs
Enhanced Services - Most provide services above Medicaid covered services (e.g., vision services for adults).
Case Management for special needs and identified populations.
Dedicated staff (or contract with organizations like CHIP) to provide outreach, education, and to visit members. Some MCOS visit members to explain program.
24 Hour Advice and Triage Nurse Helpline - A toll-free number to discuss information on a disease or illness (e.g. asthma, pregnancy) or receive advice on the treatment of a minor fever, accident or illness.
MCOs have unique programs to help manage difficult patients including drug seekers, frequent ER users and chronic disease sufferers.
Value Added Benefits of MCOs
Disease/Health Management Programs - Provide disease management programs and provide patient/outreach information on how to manage asthma, diabetes, maternity, etc.
Immunization rate of 83% is substantially above the national average of 63%.
Diabetes programs have demonstrated a decrease in hospital admission and emergency room visits.
The HEDIS measure for ‘use of appropriate asthma medications’ (87% - 95%) is above the national rate of 86%.
Falls Church
Fredericksburg
Covington
Roanoke City
SalemRoanoke
AlexandriaFairfax City
Manassas
Arlington
Charlottesville
Albemarle
Williamsburg
Matthews
Henry
Bedford
Bedford
Norton Pulaski
Radford
Lynchburg
Isle ofWight
FrederickWinchester
Lexington
Richmond
Chesterfield
Petersburg
Col.Heights
Portsmouth
Newport News
Norfolk
SouthamptonEmporiaFranklin
Galax
Bristol
MartinsvilleDanville
Rockbridge
Buena Vista
Staunton
Waynesboro
Augusta
King &Queen
NewKent
Montgomery
Prince EdwardCampbell
NorthumberlandCarolineEssex
AccomackFluvanna
Northampton
Wythe
Franklin Sussex
Wise
CharlesCity
CraigGloucester
Buchanan
Appomattox
Virginia Beach
FloydSmyth Pittsylvania
FauquierShenandoah
Dickenson
Giles
WashingtonLeeScott
Russell
Tazewell Bland
GraysonCarroll
Patrick
Botetourt
Charlotte
Amherst
MecklenburgGreensville
Suffolk
SurryDinwiddie
Amelia
Henrico
Powhatan
MiddlesexLancaster
Richmond
Hanover
King William
Louisa
Goochland
Highland Greene
Stafford
PagePrinceWilliam
Bath
Clarke
Rappahannock
Madison
Westmoreland
Nelson
Chesapeake
SpotsylvaniaOrange
Warren
Manassas Park
Rockingham
Brunswick
KingGeorge
Alleghany
Cumberland
Prince George
Halifax
Culpeper
Loudoun
York
JamesCity
Lunenburg
Nottoway
Harrisonburg
Hopewell
Poquoson
Hampton
Fairfax
Medallion II / FAMIS MCO
Map Key
Buckingham
MEDALLION / FAMIS Fee-for-Service
Update: 06/09/2011
Medallion II / FAMIS Managed Care
Roanoke/Alleghany Expansion – 1/1/12
Falls Church
Fredericksburg
Covington
Roanoke City
SalemRoanoke
AlexandriaFairfax City
Manassas
Arlington
Charlottesville
Albemarle
Williamsburg
Matthews
Henry
Bedford
Bedford
Norton Pulaski
Radford
Lynchburg
Isle ofWight
FrederickWinchester
Lexington
Richmond
Chesterfield
Petersburg
Col.Heights
Portsmouth
Newport News
Norfolk
SouthamptonEmporiaFranklin
Galax
Bristol
MartinsvilleDanville
Rockbridge
Buena Vista
Staunton
Waynesboro
Augusta
King &Queen
NewKent
Montgomery
Prince EdwardCampbell
NorthumberlandCarolineEssex
AccomackFluvanna
Northampton
Wythe
Franklin Sussex
Wise
CharlesCity
CraigGloucester
Buchanan
Appomattox
Virginia Beach
FloydSmyth Pittsylvania
FauquierShenandoah
Dickenson
Giles
WashingtonLeeScott
Russell
Tazewell Bland
GraysonCarroll
Patrick
Botetourt
Charlotte
Amherst
MecklenburgGreensville
Suffolk
SurryDinwiddie
Amelia
Henrico
Powhatan
MiddlesexLancaster
Richmond
Hanover
King William
Louisa
Goochland
HighlandGreene
Stafford
PagePrinceWilliam
Bath
Clarke
Rappahannock
Madison
Westmoreland
Nelson
Chesapeake
SpotsylvaniaOrange
Warren
Manassas Park
Rockingham
Brunswick
KingGeorge
Alleghany
Cumberland
Prince George
Halifax
Culpeper
Loudoun
York
JamesCity
Lunenburg
Nottoway
Harrisonburg
Hopewell
Poquoson
Hampton
Fairfax
Medallion II / FAMIS MCO
Map Key
Buckingham
MEDALLION / FAMIS Fee-for-Service
Update: 06/09/2011
Medallion II / FAMIS Managed CareAs of January 1, 2012
Affected Localities for January 1, 2012 Expansion
Medicaid and FAMIS managed care eligibles residing in the following localities will be affected by this expansion.
Bedford City PulaskiBedford County RadfordBotetourt Roanoke CityBuena Vista Roanoke CountyFloyd RockbridgeFranklin Co. SalemGiles WytheHenry AlleghanyLexington BathMartinsville CraigMontgomery HighlandPatrick Covington
Medallion II – Who is Included?
Medicare and Other Primary Insurance Nursing Homes Hospice Foster Care/Adoption Assistance Birth Injury Fund enrollees
Mandatory Medicaid enrollment of managed care eligible individuals into an MCO - mostly children, families and SSI.
Medicaid individuals who are excluded from MCO enrollment and will receive services through fee-for-service Medicaid include:
Those who are deemed ineligible for managed care will receive care through fee-for-service. Refer to 12 VAC 30-120-370 B for the complete list. Also, carved out services and services received prior to Managed Care enrollment are always FFS.
Managed Care Health Plans
Six health plans are approved to serve Managed Care eligiblesfor the area :
Amerigroup Virginia, Inc. 1-703-286-3972
Anthem HealthKeepers 1-540-853-5077
MajestaCare, a Plan of Carilion Clinic 1-855-606-4304
CareNet/Southern Health 1-866-240-4345, Ext. 6739
Optima Family Care 1-804-510-7434
Virginia Premier Health Plan 1-800-727-7536, Option 6
Carved-out Services
DMAS (FFS) continues to reimburse for:Community rehabilitation mental health, mental
retardation, and substance abuse treatment Targeted Case Management (Medicaid only-not
covered under FAMIS)Lead InvestigationsAbortions (only for life or health of mother)
Dental Services will continue to be provided through our Smiles for ChildrenSM program and reimbursed by DentaQuest (formerly Doral Dental)
How Members Get Enrolled
New Medicaid eligibles and former MEDALLION enrollees were pre-assigned to one of the MCOs and notified by mail in late November
Current Virginia Premier enrollees remain enrolled without disruption
Recipients must call the Managed Care Helpline by December 16th to make choice or be automatically enrolled into the pre-assigned MCO
MCO enrollment effective 1-1-12
FAMIS members will be assigned in December for January 1st
Medicaid - Changing MCOs
Ninety (90) days after the effective date to change MCOs for any reason
After 90 days changes are only allowed with approval from DMAS for good cause which is defined by regulation
Medallion II Open Enrollment (December and January). Changes become effective February 1st**
FAMIS Open Enrollment occurs on the member’s anniversary date
**Virginia Premier enrollees only this year
MEDALLION
Effective December 1, 2011, all MEDALLION clients in the expansion area returned to fee-for-service Medicaid until January 1, 2012 to prepare for MCO enrollment
If you were a MEDALLION provider, after November 2011 you will not receive the $3 PMPM from Medicaid for clients in the expansion area
Providers Must Contract
In order to see managed care members, you must contract with MCOs or receive a prior authorization
Providers may steer patients to preferred MCOs and advise that they choose particular MCOs
Know the MCO network for specialty care. Avoid referring clients to specialists outside their MCO network
MCO Contracting Requirements
We encourage you to contract with multiple MCOs
Your business needs and the MCO’s ability to meet those needs must
be a consideration
Each MCO is responsible for the development of its own provider network
The MCO provider contract defines the scope of the relationship with the plan to include reimbursement, and expectations
An MCO contract allows you to see both Medicaid and FAMIS enrollees
Each MCO has dedicated provider relations staff to help you. Get to know who they are and how to reach them
Credentialing – Consider Timing
Credentialing – As with commercial and private insurance, the plans will require that providers go through a credentialing process before becoming being part of a plan’s network
This process may take up to 90 days before contracting is completed
If You Do Not Contract
You will not be able to continue to treat managed care eligible members
For services rendered to a MCO member without benefit of a contract with the MCO or an agreement for reimbursement, your payment will be denied. Providers may not bill the member
Medical Transition
DMAS will support providers in this transition. To assist in the transition process, DMAS will be
providing the MCOs with Medical Transition Reports and Health Status Survey information from the Managed Care Helpline
This information will assure that services with authorizations, etc., are transferred to the MCOs, without disruption
If you have prior-authorized a service, the authorization must be honored by the new MCO
Eligibility Verification
Always verify eligibility! At each visit, eligibility must be verified prior to services being rendered. Providers may use the MCO eligibility verification systems or use the DMAS systems:Web-basedTelephoneSwipe card
Presentation of ID card does not guarantee eligibility
If eligibility is not verified the MCO is not responsible to cover service and the member cannot be billed
Billing
Claims for covered services provided to MCO recipients are submitted to the MCO for payment
Providers must adhere to MCO contract terms including claim submission timelines, which may differ from Medicaid
Many MCOs have electronic claim submission and payment capability
Providers cannot bill a recipient for any services provided that are covered within the State Plan
If a recipient agrees, in writing and in advance of receiving the service, to pay for a service that is not a State Plan covered service, then a provider can bill the recipient for that service
Appeals
For Medicaid:– Providers may appeal with the MCO and exhaust
the MCO process. After completing MCO process, may appeal to DMAS
– Members may appeal to MCO or DMAS or both concurrently
For FAMIS:– Providers may only appeal through the health plan.– Enrollees must exhaust MCO appeal process.– External review option available once MCO appeal
process has been exhausted. Enrollee sends request to DMAS
FAMIS Differences
FAMIS MCOs require small co-pays of $2 or $5 for most services
Non-emergency transportation is not covered (some MCOs offer a limited number of trips as an enhanced benefit)
Managed Care Resource Guide
Commonwealth of VirginiaDepartment of Medical Assistance Services
http://dmasva.dmas.virginia.gov/Content_pgs/mc-home.aspx
Medicaid Managed Care Help Line &FAMIS Central Processing Unit
Medicaid Clients can receive assistance by calling the Managed Care HelpLine at
1-800-643-2273TDD: 1-800-817-6608
8:30 am – 6:00 pm Monday through Friday
FAMIS Clients can receive assistance by calling the
Central Processing Unit at
1-866-87FAMIS(1-866-873-2647)
TDD:1-888-221-15908 a.m. to 7 p.m. Monday - Friday
9 a.m. to 12 noon Saturday
Thank You!
www.dmas.virginia.gov
www.virginiamanagedcare.com
www.famis.org